Discharge Summary: How to generate one?

📍 Navigate to: Sidebar → Patients → select patient → Discharge Summary · Full UI Guide

Whether your patient stayed at the facility for a few days or several weeks,
this article shows you how you can efficiently generate a complete discharge summary
using DeepCura:

🧱 Step 1: Create a Discharge Template

Start by creating your own discharge summary template. You can utilize the example template we created below, and edit anything you want changed.

Patient Name: [Full Legal Name]
DOB: [MM/DD/YYYY]
MRN: [Medical Record Number]
Date of Admission: [MM/DD/YYYY]
Date of Discharge: [MM/DD/YYYY]
Admitting Physician: [Physician Name, Credentials]
Discharging Physician: [Physician Name, Credentials]
Primary Diagnosis: [Full ICD-10 diagnosis or description]
Secondary Diagnoses: [List other relevant diagnoses, comma-separated]
Procedure(s): [List any procedures performed during stay or "None"]
Consults: [Specialty or Consultant Name(s), or "None"]

Hospital Course:

[Short narrative paragraph describing the reason for admission, summary of the hospital stay, response to treatment, relevant labs or imaging, any complications, and condition at discharge. Include relevant specialist interventions or consults.]

Discharge Medications:

[Medication Name, Strength] [Route] [Frequency] [Duration or Instructions]
(Example: Metformin 500 mg PO BID)
[Repeat as needed for each medication]

Discharge Instructions:

[Instruction #1]
[Instruction #2]
[Instruction #3]
(Examples: Complete antibiotic course, check glucose daily, follow diabetic diet)

Follow-Up Appointments:

[Provider/Specialty] – [Date]
[Lab/Imaging] – [Date]
(Include PCP, specialty follow-ups, and any required lab testing)

Discharge Condition: [Stable / Improved / Unchanged / Worsened]
Disposition: [Home / SNF / Rehab / With family / Other]

Physician Signature:
[Physician Name, Credentials]
[Specialty if applicable]
Date: [MM/DD/YYYY]

💾 Step 2: Save the template

To use the template above:

Select and copy the entire template.
Go to Create Templates in your workspace.
Choose Create Custom Prompts as the type.
For the Title, enter: Discharge Summary.
In the "Enter your Prompt or instruction content" field, paste the template you copied.

📘 Step 3: Build the clinical story over time

During the patient’s stay, make sure you’re adding new notes consistently through DeepCura inside their patient file. These might include:

Updates on their condition
Medication changes
New procedures or imaging results
Specialist consultations

Each note contributes to the full picture and will later feed into the discharge summary.

px threads new.png

🧾 Step 4: Auto-generate the Discharge Summary

To compile all the relevant notes into one discharge summary:

1. Click "Add note as context" for each note you want to include in the final summary.
add note as context (1).gif

2. If you’d like to add anything extra, you can either type it in the “Add patient context” box or recording it directly. If there’s nothing more to add, skip to the next step.
ADD PX context.png